Urinary urge incontinence (UI) is involuntary leakage of urine that is accompanied by a sudden desire to urinate. Prevalent, morbid, and costly (nearly $20 billion annually in 2000), UI is a major problem for older adults. Although it is generally ascribed to bladder spasms (also known as detrusor overactivity [DO]), the actual causes of UI are unknown, and therapy remains inadequate and little improved over the last 50 years. The recommended first-line treatment behavioral therapy using biofeedback (BFB) is as successful as medications and safer, but it is rarely used because it requires equipment, expertise, and time that are not widely available. The goal of our ongoing study is to determine the factors that predict BFB response and, more importantly, how BFB works. Such understanding should allow physicians to further enhance its efficacy, streamline its delivery, and facilitate its more widespread application. However, this ongoing study is suggesting that the most important factors reside not in the lower urinary tract but rather in the way the brain controls it. While little is known about such brain control, our pilot studies suggest that the key areas can be identified, as can the connections between these areas, and that there are differences between the way these centers function in older people who remain in control of their bladder and in those who develop UI. To prove that these centers are the ones involved, the findings must be confirmed in a separate and larger group of older adults. In addition, if these data are correct, then the brain abnormalities in people who suffer from UI should improve in concert with the clinical response to BFB. Thus, the specific aims of this proposal are: (1) to confirm these pilot findings in a larger group of older women (>60 years old) with and without UI; and (2) to determine whether the abnormal brain findings in those with UI improve with BFB and whether such improvement parallels the clinical improvement. To address these aims, subjects will be studied before and after an 8 week course of BFB. The evaluation will include a clinical evaluation, detailed testing of lower urinary tract function, and non-invasive brain imaging using functional magnetic resonance imaging (fMRI). Findings after BFB will be compared with those before therapy and clinical improvement will be compared with change in the brain abnormalities. In addition, because some of these people will become continent even though their DO persists, their brain changes will be compared with those of their peers in whom the DO resolves. Knowledge from this study could shed important insights into the cause of UI in older adults, as well as the mechanisms that underlie its successful treatment. In turn, such knowledge should facilitate design of therapy that is simpler and more effective so that more people can benefit.Project Narrative The learning of bladder control is a milestone in child development, and the loss of bladder control as an adult can be a disastrous experience and one that often can compromise an independent and active life. The causes of this condition are not clear, and thus therapy is not very effective and is poorly targeted. Because biofeedback-assisted bladder training is the most promising and safest of available treatments, new knowledge of how it works could allow it to become even more effective and more widely available.